Will Paid Home Care Erode Informal Support?

Abstract

One of the main barriers to the expansion of paid home care for the chronically disabled is the fear that policymakers have that it will cause friends and relatives to curtail their informal caregiving efforts. Using the first wave of the National L o n g -h Care Survey, we examine whether the amount of paid home care used by disabled elderly persons had a significant influence on the amount of infonnal support they were receiving. Results from a two-stage least squares regression analysis suggest that the amount of i n f d home care received was not significantly affected by the level of formal care. This conclusion held for subgroups of formal care users most likely to exhibit substitution: those without cognitive problems, the disabled elderly with above average income, and persons who lived alone. Even the more severely disabled elderly, who are the target of most proposals to expand paid home care, did not substitute paid care for unpaid. Thus, our study suggests that an increase in paid home care will not erode informal support.Most of the chronically disabled elderly live in the community, not in nursing homes. This is true even among the severely disabled. Family-provided help is the mainstay of home care for the elderly. In 1982, of the 4.65 million older persons in the community who had a chronic disability, roughly 90 percent depended on family and friends to remain at home (Rivlin and Wiener 1988). In the same year, only 25 percent of the chronically disabled elderly reported any paid in-home help, such as home health care, homemaker help, Support for this reseatch was provided by the Health Care Financing Administration, Cooperative Agreement 17-C99376/3-01. Judith Sang1 is the project officer. No official endorsement by either the Health Care Financing Administration or the Department of Health and Human Services is intended or should be i n f d . These opinions are those of the authors and should not be attributed to other staff members, officers, of Pustees of the Broolungs Institution. The authors gratefully acknowledge the research assistance of Robert Simon and the secretarial support of Carolyn Hill and E. Carole Hmgleton. We also gratefully acknowledge comments on an earlier draft from Sheila Murray of the University of Maryland and Kevin Coleman of Lewin/ICl?

A New Typology of Home-Care Helpers

“…Scholars have used the formal-informal dichotomy as a basis for quantifying services (Edelman & Hughes, 1990), providers (Kart & Longino, 1987), visits (Hanley, Wiener, & Harris, 1991), and hours spent by providers to give care (Kemper, 1992;Tennstedt et al, 1996). These epidemiological approaches could afford critical perspectives on key compensation issues such as fair expectations of workers and labor costs (Close et al, 2001).…”

“…In the past, there was concern about a possible reduction in government support for home care in the event of a substitution effect, in which informal helpers reduced their efforts upon the entry of formal helpers (Hanley et al, 1991). However, early support for the substitution effect (Greene, 1983;Weissert, Cready, & Pawelak, 1988) has not been evident in more recent studies (Cohen, Miller, & Weinrobe, 2001;Penning, 2002;Tennstedt et al, 1996) or in reanalyses of older studies (Penning & Keating, 2000).…”

Crowding Out Informal Care? Evidence from a Social Experiment in Germany

“…Indeed, empirical studies confirm a substitution effect between informal and formal care (Greene, 1983;Hanley, Wiener, and Harris, 1991;Ettner, 1994, Pezzin, Kemper, andRechovsky, 1996). Moreover, home care programs often have little or no retarding effect on the probability of entering a nursing home (Christianson, 1988;Wooldridge and Schore, 1988).…”

The institutional embeddedness of social capital: a multi-level investigation across 24 European countries

“…When governments institutionalized and professionalized some aspects of these relationships between people, the continuity and quality of support was increased, but it crowded out or substituted informal social capital (Janowitz, 1976;Abrams and Schmitz, 1984;Offe, 1984;Roberts, 1984;Glazer, 1988;Putnam, 2000). This view is not uncontested and a second, opposing, view emphasizes that formally institutionalized provisions may provide structures in which informal social capital can flourish and therefore a crowding in effect may have taken place (Chappell and Blandford, 1991;Hanley et al, 1991;Künemund and Rein, 1999;Rohstein, 2001;. According to this argument, the formal welfare state provisions create trust that also facilitates informal social capital to come about and to be sustained.…”